Healthcare Provider Details

I. General information

NPI: 1366440133
Provider Name (Legal Business Name): CHRISTOPHER JOHN CIMMINO D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 10/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83-40 WOODHAVEN BLVD
GLENDALE NY
11385-7824
US

IV. Provider business mailing address

8340 WOODHAVEN BLVD
GLENDALE NY
11385-7824
US

V. Phone/Fax

Practice location:
  • Phone: 718-441-4444
  • Fax: 718-849-7854
Mailing address:
  • Phone: 718-441-4444
  • Fax: 718-849-7854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number134874
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number134874
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number134874
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License Number134874
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number134874
License Number StateNY
# 6
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number137874
License Number StateNY
# 7
Primary TaxonomyN
Taxonomy Code209800000X
TaxonomyLegal Medicine (M.D./D.O.) Physician
License Number134874
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: